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Module 11
Section 2: Patient medical charts and patient profiles
Question | Answer |
---|---|
Uses of patient profiles and medical charts | Documents and communicate a patient's progress to other health care professionals Design, recommend, and monitor medication therapy. |
Which portion of a patient chart is written in the form of SOAP notes? | Physician or pharmacy progress reports |
What does the acronym SOAP stand for? | Subjective information Objective information Assessment Plan |
What is subjective information? | Data that is not measurable, such as the patient's chief complaint and history of present illness. |
What is objective information? | Data that can be measured, such as a patient's laboratory values, physical evaluation, and vital signs |
What information appears in the assessment section of a SOAP note? | The diagnosis of the patient's chief complaint |
What information appears in the plan section of a SOAP note? | An evaluation of the medication therapy a patent is taking Any appropriate new therapy Information about how to monitor a patient Patient education notes |
If a patient states that they have a bad headache, in which section of a SOAP note is this information recorded? | Subjective information |
In which section of a SOAP note is a patient's blood pressure recorded? | Objective information |
In which section of a SOAP note would the statement "Reduce alcohol intake" be recorded? | Plan |